MEDICARE: DR. SANDRA PETERSEN DNP,APRN, GNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	596367	TX
2	363LF0000X	Family Nurse Practitioner	596367	TX

General Provider Information

NPI Number	:	1548396849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA PETERSEN DNP,APRN, GNP-C

Provider Business Mailing Address
First Line	:	6827 DEL NORTE LN
Second Line	:	SUITE 101
City	:	DALLAS
State	:	TX
Zip	:	75225-2552
Country	:	US
Telephone Number	:	214-213-4726
Fax Number	:

Provider Business Practice Location Address
First Line	:	6800 WEST LOOP S
Second Line	:	SUITE 180
City	:	BELLAIRE
State	:	TX
Zip	:	77401-4528
Country	:	US
Telephone Number	:	713-981-6125
Fax Number	:	713-664-7656

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	03/20/2012

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